Jeffrey N. Bernstein MD. Simple asphyxiants Systemic asyphyxiants *Chemical irritants

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Clifford Franklin Fitzgerald
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1 Jeffrey N. Bernstein MD Simple asphyxiants Systemic asyphyxiants Chemical irritants

1746 (est) people killed overnight 3000 Cattle Countless wild animals There was no evidence of bleeding, physical trauma, or disease, and no sign of exposure to

5 1746 (est) people killed overnight 3000 Cattle Countless wild animals There was no evidence of bleeding, physical trauma, or disease, and no sign of exposure to radiation, chemical weapons, or poison gas. And there was no evidence of suffering or death agony : The victims apparently just blacked out, fell over, and died.

6 Water in lake Nyos among most still in world Temperate climate Constant temperature from top to bottom Very deep lake, disturbances on top do not stir up the bottom Methane Ethane Propane Butane Nitrogen Argon helium Carbon dioxide

7 Little risk of secondary contamination Remove patient from exposure Fresh air Symptomatic and supportive

8 the sole physician covering the emergency department (ED) was inundated with patients seeking treatment for exposure to the unidentified gas. A disaster alert was initiated immediately, and 2 additional physicians quickly arrived.

The train had been carrying 3 carloads of chlorine and 1 carload of sodium hydroxide Based on patient presentation and communications from the poison center, an irritant gas was suspected.

9 The train had been carrying 3 carloads of chlorine and 1 carload of sodium hydroxide Based on patient presentation and communications from the poison center, an irritant gas was suspected. The triage and management of more than 110 patients arriving at the local ED was based on this identified toxic syndrome. Chlorine, a respiratory irritant, was later confirmed as the sole causative agent Swimming pools Disinfectants Industrial accidents Chemical warfare

10 Toxidrome Typical Toxicants Predominant Route of Exposure Predominant Targets of Toxicity Predominant Toxicodynamics Highly watersoluble Ammonia Formaldehyde Hydrogen chloride Sulfur dioxide Inhalation Airway Corrosive local toxic effects. Dissolve in H 20 of mucous membranes of upper airway Moderately water-soluble Chlorine Inhalation Airway Breathing Corrosive local toxic effects. Dissolve in H 20 of mucous membranes of upper & lower airways Slightly watersoluble Phosgene Nitrogen dioxide Inhalation Breathing Corrosive local effects. Dissolve in H 20 of alveolarcapillary membrane Moderate water solubility Dissolves in water to form hydrochloric and hypochlorous acid Chlorine 20 x more toxic than HCL Pulls hydrogen off of water for form free radical oxygen species Zinc Phosphide Garlic or fish Sulfur Mustard Garlic Phosgene Freshly mown hay Cyanide Bitter almonds Lewisite Geraniums Arsenic and OP garlic

11 Dilution is the solution to pollution

13 SIGNS AND SYMPTOMS 0-10% No symptoms 10-20% Tightness/forehead & headache 20-30% Headache and throbbing temples 30-40% Severe h/a with n/v & dim vision 40-60% Coma and Convulsions >60% Cardiovascular collapse and respiratory failure

HYPERBARIC OXYGEN WILL HBO PREVENT DELAYED NEUROPSYCHIATRIC SEQUELAE (DNS) FROM CARBON MONOXIDE? A prospective randomized, controlled study comparing 100% Oxygen and HBO.

14 HYPERBARIC OXYGEN WILL HBO PREVENT DELAYED NEUROPSYCHIATRIC SEQUELAE (DNS) FROM CARBON MONOXIDE? A prospective randomized, controlled study comparing 100% Oxygen and HBO. N=60 Outcome measure was the development of a neurologic or psychiatric complication. DNS developed in 7/30 getting Oxygen DNS developed in 0/30 getting HBO DNS could not be predicted by symptoms or by carboxyhemoglobin level. Thom et al: Ann Emerg Med 25: , 1995

The patient had several seizures on route to the hospital. In the E.D. an ABG showed ph 6.7, pco 2 36, po 2 288 on an FIO 2 100%. Lactate 12 meq/l., COHb = 18%, MeHb= 0%.

15 The patient had several seizures on route to the hospital. In the E.D. an ABG showed ph 6.7, pco 2 36, po on an FIO 2 100%. Lactate 12 meq/l., COHb = 18%, MeHb= 0%. cyanide There was a significant correlation between CO and CN levels in fire victims. Among 114 victims of fires in France 74% had CN levels > 40 umol/l 46% had CN levels > 100 umol/l Plasma lactate levels > 10 mmol/l were a sensitive predictor of CN toxicity. Baud FJ, et al: Elevated blood cyanide concentrations in victims of smoke inhalation. N Eng J Med 325: , 1991.

16 Blood at left is from control patient, those on the right are from patients in the series

0.00011 to 0.00033 ppm Typical background concentration 0.01 to 1.5 ppm rotten egg odor 2 to 5 ppm headaches, watery eyes, nausea and sleep problems. Airway constriction in asthmatics.

19 to ppm Typical background concentration 0.01 to 1.5 ppm rotten egg odor 2 to 5 ppm headaches, watery eyes, nausea and sleep problems. Airway constriction in asthmatics. 20 ppm Severe headaches, dizziness, memory loss, irritability and fatigue 50 to 100 ppm lung and eye irritation after one hour. Loss of appetite, upset stomach. 100 ppm Two to 15 minutes: eye irritation, coughing and a complete loss of smell will occur. Lethargy, resp diff. Death may occur within 48 hours. 100 to 150 ppm: Olfactory extinction 200 to 300 ppm One hour: respiratory collapse and pulmonary edema 500 to 700 ppm death within one hour. 700 to 1000 ppm collapse and death within minutes 1,000 to 2,000 ppm Death may occur with a single breath.

20 Avoid secondary contamination! Fresh air/oxygen Irrigation of eyes/folds Nitrites Hyperbaric?

21 Bhopal December 3, 1984 Florida Poison Information Center

NJSP HMRU June 10, 2004

NJSP HMRU June 10, 2004 June 10, 2004 Chemical-Bio Agents Module 3 Overview 1 Objectives Student will: Demonstrate ability to recognize signs and symptoms of chemical agent exposure Describe how to protect oneself against chemical